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Psychiatrist outlines problems with mental health system

Editor’s Note: This letter was sent to the county commissioners of Mason, Grays Harbor, and Thurston counties.

I am a community psychiatrist, working in Thurston and Grays Harbor counties for the last 22 years, writing on behalf of my patients and colleagues to ask for your review, and hopefully your intervention, regarding Washington state’s system of mental health care for Medicaid recipients in our counties.

Mental Health provision in Washington state for Medicaid clients has devolved into a system where policies are set in place that discriminate against the mentally ill. It is a system where the real care of these patients is not only seriously underfunded, but the Regional Support Networks in Thurston, Mason and Grays Harbor counties, along with Behavioral Health Resources (BHR), have entrusted a seriously flawed negotiation of contract that is tragically leading to the decimation of mental health services in those counties. The sides have become exhausted, there is no flexibility, they are committed to a course that has destroyed confidence in workers at Behavioral Health Resources and is patently a failed exercise.

I write to you not to identify a culprit. I write because I sincerely fear the current contract is seriously myopic, the real world consequences of which have escaped the ability of the RSNs and BHR to keep in consciousness, let alone correct. Your intercession is requested.

The State Mental Health Division evolved the RSN system more than a decade ago, in order, in part, to divest them of the responsibility for managing the day to day financing of community mental health needs. The vision was to have 13 different regions, individually responsible for the management of the available dollars for mental health care, with the hope that local control would allow flexibility in the tailoring of those resources to local needs.

Early on it became clear the state was investing a tremendous amount of power and control in the RSN structure. Contrary to what the Center for Medicare and Medicaid Services envisioned, the RSNs were allowed in this state to operate with federal funds (the matching 50 percent of Medicaid funding for mental health) without opening the process to bidding from other mental health management organizations. My understanding is that CMS issued a statement requiring the Washington State Mental Health Division to open the process to bidding, late in 2013. It is my understanding that the state has responded that they have no intention to comply.

The RSNs, at their inception, quickly understood they had a monopoly situation and could dictate terms to the contractual providers. Over the last decade, there were a series of contracts that were proffered by the Thurston, Mason and Grays Harbor RSNs, to which the community mental health system could only accede. There were no real negotiations, certainly not of equals. There were demands from the RSN, with threats that contracts would not be forthcoming unless the demands were accepted.

Increasingly the demands within these subsequent contracts, in Thurston, Mason and Grays Harbor counties, have seriously eroded the ability of providers to do their job.

The RSNs in Thurston, Mason and Grays Harbor county made the issue of billing for patients one where all providers of any discipline, were paid, wholly determined, by a single flat rate for ‘face to face’ time.

From that simple beginning, there was borne a multitude of unforeseen consequences.

One particularly egregious consequence, which runs counter to quality of care, was a disincentive to have case managers or therapists attend medical appointments with patients, because that was seen as ‘double billing’, and that was not allowed. So this disincentive drove a wedge into the coordination of care for the most seriously disorganized patients in our care, who could benefit immensely from having a staff member who could get the patients to the appointment, remember the conversation, and help the patients integrate their visit. The decision to adopt this restriction had nothing to do with quality of care. It diminished care.

BHR, through contract fiat, was dropped into a situation where they were not reimbursed, at any level, for no show patients. BHR was made to bear financial responsibility for the fact that, within our population, there are necessarily some very seriously irresponsible, very disorganized, very impoverished, very ill people. It follows that there is a certain ‘no show’ rate that accompanies these predispositions. That no show rate is not a function of BHR’s lack of responsibility, lack of outreach, lack of compassion, lack of prompting or failure to remind. We at BHR, as an agency, can perform every conceivable action to counter no shows, and still, given the nature of our population, a no show rate will exist.

In the event of a no show, there are a lot of actions necessary to document, communicate, and trouble shoot the welfare of the no show patient. With the current contractual reimbursement for ‘face to face’ time only, there is somehow the notion that these necessary professional actions, by BHR employees, should occur for free, as though the no shows occur through our nonfeasance, or represent some failure on our part, as opposed to the patient’s absented responsibility.

By making BHR responsible for the financial obligations in trying to engage a difficult population that society reputedly wants to treat, by having a contract that specifically does not pay for no shows, the RSN contract successfully offloads the Public Health responsibility to engage the Medicaid mental health population, placing that responsibility, professional and financial, squarely on BHR. They do this without needing to admit that there is a cost to the process of engaging that population, without needing to agree that there is a value to this outreach, this engagement, without needing to admit there is a Public Health responsibility inherent in this process, and without agreeing to pay a cent for it to occur.

To those of us who deal with mental health consumers (who in their lifetimes are variously murderers, rapists, victims, felons, depressed, bipolar, anxiety disordered, autistic, personality disordered, brain injured, chemically dependent, or who may be children of extremely disorganized, poor families, caught in mayhem), this desire to exculpate the state’s responsibility regarding the very tangible assets necessary to engage our population seems at best extremely expedient, entirely and obviously naive. Speaking for my patients, I struggle to portray this as anything less than an action that discriminates against the mentally ill. Willfully ignoring the reality that it takes considerable professional effort to secure and continue therapeutic relations with this population. Make no mistake, not paying for no shows is a statement of disregard and disrespect for the nature of the work we are required to do.

Take my day of Feb. 11, 2014 as an example. It was a nine-hour day at a rural site in Elma. I am only there once every two weeks, so there is an hour devoted to staff review of the 15 clients scheduled to see me, along with troubleshooting cases that are deserving attention, and then again on this date there were four cases presented for referral for psychiatric evaluation. A total of seven hours and 15 minutes were devoted to scheduled patient time, over 80 percent of my day. Forty-five minutes for paperwork, 8 percent of my day. My schedule is filled for eight weeks into the future; the first appointment available is 10 weeks out. At the end of the day, five clients no show (‘dead battery’, ‘in the ER all night’, ‘too disorganized to remember’, not answering phone, phone no longer operating’), one additional client had been hospitalized, one additional client had cancelled as ill. All seven of these patients required time to review latest notes, write notes documenting the missed appointment, create e-mails to case managers, therapists and support staff to ask after the welfare of the clients, along with making sure their medications were sufficient to make it to their next scheduled appointment, so that they would not become psychotic or otherwise symptomatic before they can get in next time. During the three and a half hours these no shows are not there, I am, in addition, expected to field 30-40 e-mails on other cases that are percolating at two other sites where I work, which in turn requires, in response to those e-mails, that I check my last notes, review their medicines, get prescriptions to pharmacies. In my ‘down time’ I am, in addition, expected to review and correct transcription, to finalize notes for the chart.

None of that time in the current contract is billable. But all of it, 100 percent, is professionally necessary. Doing anything less is malpractice.

Of the remaining appointments, being scrupulous about time spent with the client ‘face to face’ only, and working with a patient who walked in without an appointment during my one mid day paperwork, I collected three hours and 17 minutes. That is less than the desired an expected number of 5.6 hours that I am instructed to average by administration on a nine hour work day. So it redounds to me from administration that I am a deficient producer. And the statement of administration is that if I do not reach my hours of ‘face to face’ time, there will be disciplinary measures.

After years of calculating these figures, I, along with others, have come to the conclusion that if you miss work during a month, for whatever reason, even if it is within your benefits (accrued sick time, accrued vacation, accrued education leave), the odds are you will not make your yearly hours. The arguments used by administration to make their case to the contrary, that the expected figures are entirely reasonable, fundamentally do not reflect the real calculus of the uniquely problematic issue of no shows, as it exists in our clinical reality. The expectation of the RSNs and BHR administration that we exert ultimate control of ‘face to face’ productivity has become seriously unmoored from what happens in real time. More difficult yet for line staff is the complete absence of respect for the quality and execution of our job, one of which purposes is precisely to collect the less than compliant patients before they wreak havoc in our communities. That time for shepherding the wayward cases is counted against us, as it does not count as ‘productivity’.

The RSNs and BHR have hit an impasse that was conceived when they worked out their expedient contract, and the very construction of that contract, and the defense of it despite its unworkable tenants, is destroying the confidence and morale of all workers at BHR, all of whom see the folly of this design.

We are all being told that we are going to be held individually responsible for the production of numbers for ‘face to face’ productivity that are not in our control. We are being treated as though we are individually responsible to reverse the socioeconomic factors, the epidemic of chemical dependency, the interference of mental disorders and irresponsibility that is particularly most true in exactly the people we are tasked to see.

We are not in the private sector, we may not charge for missed appointments, there is no financial disincentive for our population to miss appointments. This is not Group Health, this is not Kaiser Permanente, not private practice. We are threatened with disciplinary action if our hours are not met. Yet the rules are disproportionate; expected to meet private sector productivity numbers while there is no parity in the disincentives for missing.

Make no mistake, the talented people here will leave.

The system is broken, the model is flawed, and the participants (BHR and RSNs) have no creative ideas to fix this. The current course is headed for labor action and departure of valued staff. The RSNs and administration of BHR are not evidencing the capacity to negotiate a workable solution. They are mired in the misguided certainty that they are proceeding correctly. While they are proceeding to the end of BHR as we know it.

I make no apology for the difficulty of my work. I do not work at Macy’s cosmetic counter. I make no apology that it is at times toxic to extremely disorganized, psychotic patients to be forced to endure appointments of 25 minutes. It is not always in their best interests, it can lead to unpredictable situations where explosive tempers, assaults or destruction of property can occur. Conceptualizing the care of the mentally ill as though it is a retail enterprise is wholly naive and ignorant. Getting paid less for foreshortening a clinical encounter, because of exercising sound judgment that may preclude or avert a looming disaster in a very complicated case, that is an insult. The premise that more time with a patient always equals better benefit to the patient is false. Only a person who does not do this job for a living would maintain otherwise.

Certainly, not all the actions of RSNs are working against the care of the mentally ill. We are told it is indeed likely that insurance companies or independent mental health contracting organizations, if bidding at the state level were opened, would refuse to pay for case management and/or therapy. That would be a nightmare of a different sort. So I recognize that the RSN and BHR are locked into their positions, precisely because they can’t see a solution. There needs to be a broader discussion. I call upon your goodwill and legitimate office to investigate these issues. The losers are going to be the poor with mental health needs. No one speaks for them.

My suggestion is for the commissioners to consider immediately pulling back control of the negotiating process.

With all due respect, possible courses of action would include, but not be limited to:

Hold public hearings where these issues can be voiced. From this information, policy decisions may be fashioned that are informed, and not discriminatory. For clearly, any agency in existence to provide for the care of the mental health needs of the Medicaid population that does not fund one cent to engage those people, is shirking, if not abdicating, responsibility.

Determine to let BHR operate under a block grant, free from the deleterious effects of the ‘face to face’ rule, until the RSN and BHR can demonstrate to you that they are capable of developing a strategy that does not impede or punish the correct actions of the professionals committed to the care of the mentally ill Medicaid population. Which most certainly is not the case now.

Assign an arbitrator to sit down with the sides to allow for the process of real binding negotiations, where the RSN is not automatically empowered to dictate terms. That would be helpful, as they evidence no awareness of the downwind cost to the public of their perseverative stance on ‘face to face’ time, as the single determinant of productivity.

The issues I present to you are undoubtedly coming to you from multiple sources. But we all share common ground on this. All employees at BHR are afraid for the same reason. The management is without answer to the fundamental reality that their contract with the RSN is not feasible. Pure and simple.

Medical colleagues of mine are planning their escape routes; as are, equally, non-medical staff. They are quite clear that they will not allow their good efforts and professionalism to be tarnished by administrative punitive measures. They will not stay in an agency that wishes to base their evaluations on assumptions that bear little relation to the reality of the population served, or the real conduct of the provision of their highly professional mental health care to their patients. Once this contractual condition is made adequately visible to future candidates, BHR will be predictably and seriously hampered in recruiting replacement staff while this ‘face to face’ rule, and punitive administration policy, stand.

There is sadness in our ranks that the divide engendered by these issues has caused. I have never experienced a comparable withering of morale in my 22 years of care in community psychiatry. It is like your parents are locked in an argument, and their solution is “Damn the kids.”

We, the professionals who serve to keep this community safe by providing much needed mental health care, we need your help with this. You are uniquely empowered to have the ability to intercede. Thank you in advance for your time and consideration on behalf of the employees of BHR and the people we serve. If I can be of any assistance in explaining any of this, please call.